PHAMILY EYE CARE

Click to complete this section if you wish to authorize additional person(s) access to your health information.
Disclosure of Health Information

I authorize release of my health information to the following person(s)/healthcare provider:
Name (1)
Relationship to patient (1)
Phone/Email (1)
Name (2)
Relationship to patient (2)
Phone / Email (2)

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Office Policies

Financial Agreement & Acknowledgement of Receipt of Notice of Privacy Practices

I understand that all services rendered to me and charged are my personal responsibility for timely payment: including co-payments, deductibles, and non-covered services remaining after my insurance has paid. I understand that it’s my responsibility to know my insurance coverage. I authorize use of the signature on this form for insurance claim submissions, and for insurance to be filed on my behalf based on the information given on the date of service. I also authorize release of my medical information via email and understand it may be unsecure.

I understand that there are NO refunds on professional fees, and that follow-up visits outside 30 days will incur a fee.
Notice of Privacy Practices
Please select all of the following to indicate your understanding:*

Yes, I understand and agree to the office financial policies and have had my questions addressed.Yes, I have read or been giving the opportunity to read the Notice of Privacy PracticesYes, I consent to having my electronic signature represent my agreement to all above terms.
Signature agreeing to all above terms*

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Medical History